Angry with herself for replaying the same old complaints and rationalizations, Gwen turned off the cassette. She thought about being a medicine resident. She wasn’t ambivalent. She had to change her life. That decided, she fell asleep.
Just as the sky lightened, Gwen awoke from a dream. She had been in her childhood bed, almost asleep, when startled by loud noise. Her parents’ voices were raised in argument, unheard of in this household. Over and over, they shouted, “Larry! Larry!”
The dream had been eerily precise. Every detail—the feel of her pillow and blanket, the plaid pajamas she was wearing, the pine odor of the cleaning solution her mother used to mop the floors—was identical to the real event, except for the name they had shouted.
Gwen’s older brother, Jack, had been sixteen at the time. His temper was igniting at the least frustration. The morning after her parents’ argument woke her, Jack slammed a window shut, shattering the pane. He was still upstairs when she left the house. At recess, a girl with an older sister at Pasadena High told her Jack had been suspended from school for fighting.
Jack’s name continued to be shouted behind her parents’ bedroom door. A week later, her father moved out of the house.
Jack went back to school, briefly. He was arrested for car theft and sent to juvenile hall. Her mother wept fiercely, but Gwen didn’t offer comfort. She was infuriated by her mother’s incompetence and terrified of the consequences. Jack was a criminal, her father had abandoned them, and her remaining parent was falling apart.
After three months in detention, Jack came home. Her mother wouldn’t discuss Jack with her, yet she demanded Gwen’s presence whenever she spoke to him, leaving Gwen to wonder if she needed her daughter’s moral support or simply a witness in order to confront him. The same day Gwen received a letter from her father announcing he was divorcing her mother and moving to New York City, Jack informed them he had flunked out of high school.
Her mother finally took a stand. She refused to give Jack spending money. He got a job as a dishwasher in a drive-in restaurant. Jack had odd hours and often didn’t return at night. Then he stopped coming home at all.
When Jack eventually did reappear, his lips were dry and cracked. His hands trembled, and he smelled of vomit. The few words he said were untethered to each other. Her mother sat speechless, dabbing her eyes.
“What are your plans?” Gwen asked him meekly, prepared to receive a volley of verbal abuse.
Head down, Jack didn’t answer. He gave her a furtive, hangdog glance.
“Please, Jack. We need to know.”
“I’m going to enlist,” he said, staring at his plate.
“Enlist?”
“In the army.”
“Why?”
“So I won’t have to steal to pay for brandy. Sooner or later, probably sooner, I’ll get caught and go to prison. No juvenile hall next time.”
“How will joining the army help?”
“I can’t drink, except when they give me a pass. Then I can use my paycheck to cover bar bills.”
“That’s silly. You don’t have to join the army to stop drinking.”
“Easy for you to say,” he snarled. “You don’t have to live with being like this.”
The next morning, they drove Jack to a recruitment center where he boarded a bus for boot-camp in the Mohave Desert. Gwen saw him once more. He came to her high school graduation dressed in a spotless, starched khaki uniform. They corresponded by letter afterwards. She was certain he would have come to her college graduation too, if it hadn’t been for a sniper’s bullet in Vietnam.
XII
KEVIN WAS BACK IN the ICU at dawn. He found every oxygen reading from Larry Winton’s arterial blood line had been less than fifty since midnight. Larry’s cheeks were the dusky grey-blue of dying violets. It was miraculous he hadn’t died yet from a cardiac arrest. Kevin adjusted and re-adjusted ventilator settings, without seeing any improvement.
After rounding with his interns and student on the team’s other patients, Kevin returned to the ICU to write a progress note. Slumped on a stool, he transcribed data onto a clean sheet of lined paper—breathing and heart rates, sodium and potassium levels, blood carbon dioxide and oxygen pressures. As soon as he finished listing the facts, he was defeated. All he could write in the “Assessment” section of the note was “Idiopathic pneumonia. Grim prognosis.” Neither Kevin nor any of the attending physicians involved in the case could explain the cause of Larry Winton’s impending demise.
Twenty-seven years old and a benign medical history, Kevin thought. OK, he used to shoot drugs, but that was years ago. He was gay, but why would that matter? What did I miss? Previously healthy twenty-seven-year-olds admitted to the hospital do not die unless the house staff royally blow it. Shit!
He wrote “Plan” and left the rest of the page blank. His only plan was to wait for Herb to bring news from pathology and deliver an opinion on whether this patient’s life might be salvageable.
He looked up as Gwen was entering Larry’s room. He saw her flinch on discovering Larry paralyzed and comatose, an endotracheal tube in his nose, a gastric suction tube in his mouth. Still, Kevin was glad to see her. He wanted to commiserate.
“What did the bronch show?” she asked when he appeared at the bedside.
“Not much. More confirmation it’s not bacterial pneumonia or TB. There are still some special stains pending.”
“God, I completely blew it. He was in my exam room two weeks ago. Our social worker would have given him a taxi voucher to come here the same day if I’d just asked.”
“Hey, we’re all in the dark. Herb and Flagler don’t even have a good guess as to what the diagnosis is. If nobody can figure out why he’s dying, a delayed diagnosis doesn’t change the inevitable.”
“Thanks, Kevin, but if a bronch had been done two weeks ago and it was negative, you’d have had time to get a surgeon to do an open lung biopsy before he was this far gone.”
“Maybe,” he conceded, chastened by having underestimated her clinical acumen, “though elective OR procedures like that get pushed back for days by all the trauma cases coming here. Actually, I’m afraid we’re going to find something I should have thought about when he first walked in the ER door. That’ll be on me.”
Gwen nodded sympathetically then frowned.
“Then the two weeks before that are on me.”
“I don’t think so. The bar is totally different for a clinic doc. You’d need ESP to pick out the one in ten thousand patients with a cough and weight loss who’s going to turn out to be a zebra and crash like this.”
“Maybe.”
She looked at the ICU entrance and said, “Uh-oh.”
Kevin turned around to see Herb marching toward them. He jumped up to intercept Herb at the nurse’s station.
“What’s his arterial oxygen?” Herb demanded.
Herb had never spoken to him so curtly. It unnerved Kevin. He responded immediately, forthrightly, as he had when a schoolboy, caught red-handed committing a venial sin by one of the nuns.
“It’s been in the forties since midnight,” Kevin confessed, half-expecting Herb would order him to say thirty Hail Mary’s.
Instead, Herb’s shoulders sagged. Head bent down, he whispered an expletive. When Herb lifted his gaze, Kevin saw no anger, only resignation.
Gwen joined them. Herb mechanically acknowledged her presence.
“The silver stain is positive for Pneumocystis,” said Herb.
“That’s what the path showed?” said Kevin in disbelief. “Isn’t Pneumocystis a parasite?”
“That’s right.”
“I thought it just occurred in immunocompromised people?”
“Exactly.”
Gwen, who knew even less about Pneumocystis than Kevin, asked if the infection could be treated.
“We can give him trimethoprim-sulfamethoxazole. Though at this point, it’s not likely to make a difference.”
Holding up the blood gas printout as e
vidence, Herb added, “He’s had so much lung destruction, the odds of his ever getting off the ventilator are nil. And with these numbers, he’s had enough hypoxic brain damage that if he does survive, it’ll be in a vegetative state.”
Kevin and Gwen reddened simultaneously.
Gwen stared at Kevin. How could he possibly think it was his fault now, she asked herself.
“Guys,” Herb said gently, “treating Pneumocystis pneumonia is just winning a battle. You still lose the war if the underlying immune deficiency can’t be reversed.”
Neither Kevin nor Gwen was mollified.
Herb looked away and said, “You’re right. There’s no good excuse for losing a patient to a treatable infection, especially when it’s one you’ve seen before.”
Gwen’s remorse was supplanted by amazement. This senior specialist had just taken on the entire responsibility for Larry Winton’s imminent death, while two other candidates stood by, ready and willing to accept the blame.
“You’re sure it’s Pneumocystis?” asked Kevin, his eyes deflected downward.
“Think about it. The x-ray appearance, the time course of his illness, the negative micro studies, no history of an autoimmune condition to account for his lung disease. At NIH, I saw kids with leukemia who developed Pneumocystis pneumonia on chemotherapy. Clinical course and findings exactly like this case. Which is why I asked the lab to do a silver stain on the bronch washing. They thought I was nuts, but the slide had textbook cysts. Lots of them. Of course, that raises the question of why the hell this young man’s immune system wasn’t working. He wasn’t getting chemotherapy. He wasn’t getting steroids. He didn’t have a history of serious infections like someone with a congenital immune deficiency would have. It doesn’t make sense.”
Perplexed, Gwen nodded in agreement. Kevin went off to retrieve the chart and began writing a medication order for trimethoprim-sulfamethoxazole. As he asked Herb about the dose, she returned to Larry’s room. She watched the monitor tracking his heart’s electrical activity. A white dot moved across the screen, forming a series of identical waves. Suddenly, the pattern disintegrated into chaotic spikes.
“Code Blue!” she screamed.
Kevin rushed in, followed by Herb and two nurses. The white dot now made a flat line as it crossed the screen. Reflexively, Kevin stacked the heels of his palms over Larry’s sternum. Arms outstretched, he rocked up and down until he saw Herb shaking his head mournfully.
Kevin stopped rocking. He looked at the wall clock. He was supposed to say the time of death out loud. He couldn’t make himself do it.
XIII
THE IMPORTED LIGHT BEER Kevin opened on returning to his studio apartment was the only sign of any sophistication or health consciousness acquired since he had moved to San Francisco. He felt lonelier than usual tonight and thought of his mother. He hadn’t talked to her in weeks. His wristwatch showed seven o’clock, not too late to call Boston.
Francine Bartholomew had prematurely turned gray while Kevin was in high school. When he and his older sister, Katherine, were children, their slim, reserved mother was the obvious source of their red hair and green eyes. The daughter of a policeman, a bully who expected to be served by women, she had all ambition, beyond that of making a good marriage, snuffed out at an early age. Intelligent enough to have gone on to college, she quit school at sixteen to work as a cashier. At twenty, she moved from the modest bedroom she shared with two sisters into smaller boarding house quarters with her new husband. He had set one condition to his marriage offer—a taboo on her working outside the home.
His mother didn’t answer on the first ring, which struck Kevin as strange. Then he realized it wasn’t Sunday, the usual evening he called her.
“Hello,” his father gruffly answered.
Paralyzed by the sound of this voice he hadn’t heard in three years, Kevin was mute. There was a loud clack as the receiver on the other end of the line slammed down. Angry, and at the same time curious, he dialed the number again.
“Who is it?” yelled his father.
“Hi, Dad.”
There was a pause before his father spoke again, now from a distance. Kevin imagined the old man holding the receiver at arm’s length to prevent contamination.
“It’s your son, Francine.”
After another pause, he heard his mother’s voice.
“Kev, are you all right?”
“I’m good, Mom. Sorry I haven’t called in so long. It’s been super busy at work.”
“You’re sure nothing’s wrong?”
“Everything’s fine. Don’t worry, they haven’t cut my salary.”
Kevin knew this would calm her. By her standards, he was already making a decent living—though she had no idea what it cost to live in San Francisco—and he would be doing much, much better in the near future. If he reassured her on that point, maybe she could control her other fears. Maybe they could even have a pleasant chat.
“Dad OK?”
“The same. The doctor doesn’t seem concerned.”
Their conversation followed a well-trod path. They kept to the ruts like pack mules, both pretending his father hadn’t just refused to talk to him.
Kevin’s parents still lived in the tiny three-bedroom brick row house where he and Katherine had grown up, nestled in an all-white, all working-class, virtually all Irish-Catholic, South Boston neighborhood. A safe, comfortable world until he turned fourteen and discovered how different he was from everyone else.
“Kevin, could you come home next month for Douglas’s confirmation?”
His mother had deviated from the script. He deflected her question by asking the date. But instead of scrambling for an excuse, he remembered that Douglas was the youngest of Katherine’s four children. His confirmation would be the last family event at Saint Brigid’s until someone married or died, more likely the latter. Kevin understood how important this must be to his mother. She didn’t ask much of him. He really should go.
He promised to check his schedule and steered them back to a familiar trail by mentioning the weather. As Francine chanted her litany of Boston’s winter horrors—treacherous black ice, merciless cold winds, unreliable coal furnaces—he thought of how a trip east would also mean having to deal with his sister and brother-in-law. That could be as bad as seeing his father.
Kevin’s childhood with Katherine, a willowy attractive girl precociously adept at making friends, was a peaceful coexistence despite her ignoring him in elementary school and treating him with icy superiority in high school. His animosity came later, while he was an undergraduate at U Mass still living at home. By then, he had a circle of gay friends, kept secret from his family. One Saturday night, he was strolling across Harvard Square with a couple holding hands. They ran into Katherine and her fiancé, Ben, a Vietnam veteran. It took Katherine a brief inspection for the nickel to drop. Kevin watched the corners of her mouth turn down in disgust and her lips form the words, “This explains everything.”
To Ben, having a faggot as a future brother-in-law was a joke, at first. Then Kevin graduated from U Mass and was drafted. At his induction physical, Kevin was graphically credible in describing his sexual preferences. He fabricated a weak story for his family. A bad knee, the same implausible excuse he had employed to avoid gym class, made him ineligible. Ben saw through the charade. Having risked his life in Vietnam, he was furious. Kevin’s father and mother didn’t press the point, but Katherine did. Kevin lashed back. His anti-war sentiments came roaring out of the closet. He berated Katherine in front of them, challenging her assumptions about who the real aggressors were in Southeast Asia, knowing she wouldn’t play her trump card. Outing him would devastate their parents, and she would have to bear the consequences. He could leave South Boston. She couldn’t.
After two years of working construction, Kevin started medical school. A scholarship and loan allowed him to move from the brick row house to an apartment shared with other students. Yet he was still uneasy about being openly g
ay. There was always the possibility he might run into his parents or someone they knew. The simplest solution was to go away for residency training.
Ironically, just before he moved to California, his father overheard him telling a friend on the telephone how he could finally be out of the closet in San Francisco. Since then, his father had refused to speak to him. That was doubly ironic now. Kevin had found being a single, gay man here more lonely than liberating.
His mother signaled she was ready to end with her standard remark about how expensive long distance calls were. Departing from the script a second time, she pleaded with him again to return for his nephew’s confirmation.
She’s never asked me twice in the same call to come to Boston, he thought. Is there something she’s not telling me? Could she or Dad have a terminal illness? Despite his aversion to seeing them, Kevin hadn’t abandoned all hope of salvaging these relationships.
“I love you, Mom,” he said in a rush. “I’ll try to get to Douglas’s confirmation.”
He hung up the phone and headed out to a bar in the Castro. Kevin was exhausted. He didn’t expect to meet anyone who would be interested in more than a quick fling, which no longer appealed to him. It only exacerbated his loneliness. But he did think another drink or two and the opportunity to talk about anything other than medicine, however superficial and awkward, would distract him enough to fall asleep when he came home.
XIV
THREE MONTHS LATER, KEVIN ran into Gwen outside the City Hospital auditorium.
“Hey,” he said, pleasantly surprised, “What are you doing here?”
Before she could reply, he deduced the answer.
“You are serious about coming back if you’re here for an update on septic shock. That’s not outpatient medicine.”
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